email@example.com WELCOME TO EASTSIDE AUDIOLOGY Thank you for contacting us. Your care and privacy is our top priority.
We would appreciate if you would complete the attached forms prior to your visit and bring them with you. Doing so will save you time on the day of your visit. The forms can be filled out by computer or handwritten.
Please bring the following items with you on the day of your visit:
INSURANCE CARD(S) and PHOTO ID REFERRALS: If a referral is required for insurance purposes, the information will be found on the back of your insurance card. Please arrange to have the appropriate referral prior to your visit. In most cases, it is necessary to obtain the referral from your primary care physician. If you do not have an appropriate referral on the day of your visit, you must make payment in full and receive reimbursement directly from your insurance carrier.
PRIOR TESTS: If you have results from previous examinations, please bring them with you on the day of your visit.
CO-PAYMENTS: Co-payments are due at the time of your visit.
Helpful Hints: Refer to your insurance card for any questions regarding referral information, coverage or co-payments. If you have any questions, please feel free to call us at (212) 327-1155 or email us at firstname.lastname@example.org.
We appreciate your choice of Eastside Audiology for your hearing care needs.
We look forward to seeing you at your visit. Sincerely, Dr. Ellen Finkelstein, AuD., FAAA
EASTSIDE AUDIOLOGY Please fill out the following form online and then print and save or forms may be printed and handwritten. To use online form, just tab between various fields.
The undersigned hereby authorizes the release of any information relating to all claims for benefits on behalf of myself and/or my dependents. I further expressly agree and acknowledge that my signature authorizes EASTSIDE AUDIOLOGY to submit claims for benefits rendered. I understand that I am financially responsible for all charges incurred and understand that any insurance benefits paid will be credited to my account in accordance with the above assignment. I authorize release of information to my insurance company, to my physician, and to the following other parties, with the reasons noted.
Subscriber Signature:____________________________________________________Date__________________________ I have received a copy of Eastside Audiology Notice of Privacy Practices Signature of Patient/Guardian:____________________________________________ Date__________________________ EASTSIDE AUDIOLOGY 162 East 78th Street, New York, NY 10075 (212) 327-1155 DIZZINESS/IMBALANCE: (IF NONE, GO TO NEXT SECTION): Lightheadedness _ ____Yes _____No
Swimming Sensation in the head ____Yes _____No
Objects or you spinning ____Yes _____No
Loss of balance when walking-veering to ____Right _____Left
Tendency to fall _____Right _____Left _____Forward ____Back
Blacking out ____Yes _____No
Loss of consciousness ____Yes _____No
Nausea and/or vomiting ____Yes _____No
Headache ____Yes _____No When did your dizziness first occur?
Do you know of any possible cause of your dizziness?
Were you exposed to any irritating fumes, paints, etc. at onset of the dizziness?
Have you ever injured your head? ______Yes _____No How often do attacks occur? Is your dizziness constant or does it come in attacks?
Can you tell when an attack is about to start?
Does change in position make you dizzy?
When you are dizzy, can you stand unsupported? _____Yes _____No
ABOUT YOUR HEARING: Do you have any of the following symptoms: Difficulty in hearing? _____NO ___BOTH EARS _____RIGHT _____LEFT Noise in your ears? ____NO ____BOTH EARS _____RIGHT _____LEFT Pain in your ears? _____NO ____BOTH EARS _____RIGHT _____LEFT Fullness or stuffiness in your ears: _____NO ____BOTH EARS ____RIGHT _____LEFT If yes, does this change in any way when you are dizzy? ____YES ________NO
EASTSIDE AUDIOLOGY 162 East 78th Street, New York, NY 10075 (212) 327-1155 Drainage from your ears? _____NO _____BOTH EARS _____RIGHT _____LEFT Have you had a previous hearing examination: ________YES ________NO If yes, where was it performed and by whom:
Do you have any history with hearing aids? ________YES ________NO If yes, please provide brief details:
Have you experienced any of the following symptoms: Double/blurred vision or blindness? _______YES ______NO Numbness of face or extremities? _______YES ______NO Weakness of arms or legs? _______YES ______NO Clumsiness of arms or legs? _______YES ______NO Confusion? _______YES ______NO
OTHER IMPORTANT FACTORS: Significant Medical Problems:
Is there anything else you would like to share regarding your health?